Transcript Primary Care in the HIV-positive Individual Jessica Yager, MD STAR

PRIMARY CARE IN THE HIVPOSITIVE INDIVIDUAL
JESSICA YAGER, MD
STAR PROGRAM
SUNY DOWNSTATE MEDICAL CENTER
JULY 15, 2015
LEARNING OBJECTIVES:
 Understand important aspects of the initial evaluation in
individuals with HIV
 Appreciate similarities and dif ferences in the primary care of
HIV-positive and HIV-negative individuals
 Be familiar with available resources and guidelines
INITIAL EVALUATION
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CBC and CMP
HIV confirmation!
CD4 count and percent
HIV viral load
HIV resistance testing
Co-receptor tropism assay
Glucose-6-Phosphate dehydrogenase
HLA B5701 testing
Fasting lipid panel
Urinalysis and calculated CrCl
CASE 1: BASELINE TESTING
 A 44-year-old man comes to clinic to establish longitudinal care for his
HIV disease. He recently was diagnosed with HIV infection, but believes
he likely acquired HIV year s at least 5 year s earlier from a male sex
par tner who subsequently developed AIDS. In addition, he injected
drugs "on a few occasions" more than 10 year s ago while living in
Cincinnati, Ohio. Physical examination reveals seborrheic dermatitis
and oral candidiasis. As par t of the initial evaluation of this patient,
you order a complete blood count, comprehensive chemistries
(including hepatic aminotransferase levels), CD4 cell count, HIV RNA
level, and a tuberculin skin test. To assess exposure to other infectious
agents, you per form additional serologic testing. Which one of the
following tests is appropriate to order at this initial visit?
A. anti-Toxoplasma IgG
B. Hepatitis C genotype
C. anti-Histoplasma IgG
D. Serum cr yptococcal antigen
CASE 1: ANSWER
 anti-Toxoplasma IgG
 Serologic testing to determine previous infection with
Toxoplasma gondii is indicated for all patients infected with
HIV. Almost all cases of toxoplasmosis involving HIV -infected
persons occur as a result of reactivation of latent infection.
According to United States guidelines for the prevention and
treatment of opportunistic infections, patients who are
seropositive for anti -Toxoplasma IgG should initiate primary
prophylaxis against Toxoplasma encephalitis when the CD4
count is less than 100 cells/mm 3 . Patients without evidence
of prior Toxoplasma infection can be counseled in ways to
prevent infection.
INITIAL EVALUATION CONTINUED:
COINFECTION AND COMORBIDITIES
 TB screening: TST vs IGRA
 Repeat testing in those with negative screens and advanced AIDS
 Close contacts of individuals with active TB: treat for LTBI
 Toxoplasma gondii screening
 Hepatitis
 HAV
 HBV
 HCV
 CMV screening
SEXUALLY TRANSMITTED INFECTIONS
 Syphilis screening
 At initiation of care; periodically thereafter depending on risk
 When to refer for LP?
 Reactive RPR if ANY neuro/occular s/sx
 Serologic treatment failure (failure to reduce titer by 4 -fold after appropriate
therapy)
 Trichomoniasis screening*
 All women
 Chlamydia
 All women ≤25yo
 All women and men at initial presentation and annually thereafter (if at
ongoing risk for infection)
 Gonorrhea
 All women and men at initial presentation and annually thereafter (if at
ongoing risk for infection)
 Follow -up testing in 3 months: GC, CT and trichomonas
*Area of discordance between guidelines
CANCER SCREENING: HPV-ASSOCIATED
 Cervical cancer
 Pap at initiation of care
 If normal: again in 6 months, then annually
 Refer for colposcopy for any abnormality
 Anal cancer
 Anal pap smears in: MSM, women with a history of anal receptive
intercourse, woman with dysplasia on cervical pap
 HPV vaccination in:
 Females and males aged 9-26 years
CASE 2: PCP PROPHYLAXIS
A 38-year-old man presents for care with newly diagnosed
HIV infection. In the past 12 months, he has received
treatment for three episodes of community -acquired
pneumonia. He currently takes no medications, but in the
past he has taken azithromycin (Zithromax), penicillin, and
trimethoprim-sulfamethoxazole (Bactrim, Septra) without
difficulty. He currently has no respiratory symptoms and
his physical examination is notable for seborrheic
dermatitis, poor dentition, and extensive oral candidiasis.
His initial laboratory studies show a CD4 count of 214
cells/mm 3 and a positive IgG Toxoplasma antibody. Which
of the following is true regarding prophylaxis for
Pneumocystis pneumonia?
CASE 2, CONTINUED:
A. This patient should receive Pneumocystis pneumonia
prophylaxis, but prior to initiating prophylaxis, a sputum
sample should be sent to perform Pneumocystis jiroveci
resistance testing.
B. The patient does not need Pneumocystis pneumonia
prophylaxis; he should start prophylaxis if his CD4 count
decreases to less than 200 cells/mm 3
C.
The patient should start on Pneumocystis pneumonia
prophylaxis using trimethoprim -sulfamethoxazole at a dose of
one double strength tablet per day.
D. The patient should receive Pneumocystis pneumonia
prophylaxis, but first should undergo bronchoscopy to rule out
active Pneumocystis pneumonia prior to receiving prophylaxis.
CASE 2: PCP PROPHYLAXIS
A 3 8 - ye a r - o ld m a n p r e s e n t s f o r c a r e w i t h n ew l y d i a g n o s e d H I V i n f e c t io n . I n t h e p a s t
1 2 m o n t h s , h e h a s r e c e i v e d t r e a t m e n t f o r t h r e e e p i s o d e s o f c o m m uni t y - a c q ui r e d
p n e u m o n i a . H e c u r r e n t l y t a ke s n o m e d i ca t i o n s , b u t i n t h e p a s t h e h a s t a ke n
a z i t h ro myc in ( Z i t h r om a x ) , p e n i c i ll i n , a n d t r i m et h o p r i m - s ulf a m et h oxa z o le ( B a c t r i m ,
S e p t r a ) w i t h o ut d i f fic ul t y. H e c u r r e n t l y h a s n o r e s p i r ato r y s y m p to m s a n d h i s p hy s i ca l
ex a m i n a t i o n i s n o t a b l e f o r s e b o r rh e i c d e r m a t it i s , p o o r d e n t i t i o n , a n d ex te n s i v e o r a l
c a n d i d i a s i s . H i s i n i t i al l a b o r ato r y s t u d i e s s h o w a C D 4 c o u n t o f 21 4 c e l l s / m m 3 a n d a
p o s i t i ve I g G Toxo p l a s m a a n t i b o d y. W h i c h o f t h e f o l l ow i n g i s t r u e r e g a r d in g p r o p hy l ax i s
f o r P n e u m o c ys t i s p n e u m o n i a ?
A.
T h i s p a t i e n t s h o u l d r e c e i v e P n e u m o c ys t i s p n e u m o n i a p r o p hy la x i s , b u t p r i o r to
i n i t i a t i n g p r o p hy l a x is , a s p u t um s a m p l e s h o u l d b e s e n t to p e r fo r m P n e u m o c ys t i s
j i r ove c i r e s i s t a n c e te s t i n g .
B.
T h e p a t i e n t d o e s n o t n e e d P n e u mo c ys t i s p n e u m o n i a p r o p hy l ax i s ; h e s h o u l d s t a r t
p r o p hy l ax i s i f h i s C D 4 c o u n t d e c r e a s e s to l e s s t h a n 2 0 0 c e l l s / m m 3
C.
T h e p a t i e n t s h o u l d s t a r t o n P n e u m o c ys t i s p n e u m o ni a p r o p hy l a x is u s i n g
t r i m et h o p r i m - s ul f am et h oxa z o l e a t a d o s e o f o n e d o u b l e s t r e n g t h t a b l et p e r d ay.
D.
T h e p a t i e n t s h o u l d r e c e i ve P n e u m o c ys t i s p n e u m o ni a p r o p hy l a x is , b u t f i r s t s h o u l d
u n d e r g o b r o nc h o s c opy to r u l e o u t a c t i ve P n e u m o c ys t i s p n e u m o ni a p r i o r to
r e c e i v i n g p r o p hy l a x is .
CASE 2, ANSWER:
 The patient should start on Pneumocystis pneumonia prophylaxis
using trimethoprim-sulfamethoxazole at a dose of one double
strength tablet per day.
 This patient has two indications to
receive Pneumocystis pneumonia prophylaxis: (1) oral candidiasis,
and (2) an AIDS-defining illness (two or more episodes of bacterial
pneumonia in a 1-year period is an AIDS -defining illness).
Trimethoprim-sulfamethoxazole is the preferred agent
for Pneumocystis pneumonia prophylaxis. Furthermore,
trimethoprim-sulfamethoxazole provides protection against
Toxoplasma encephalitis and may provide some benefit in
preventing further episodes of community -acquired pneumonia.
Patients with a history of a mild -to-moderate rash caused by
trimethoprim-sulfamethoxazole can often undergo successful
trimethoprim-sulfamethoxazole desensitization.
CASE 3: TOXOPLASMOSIS PROPHYLAXIS
A 48-year-old HIV-infected woman from Mexico presents to
clinic for primary HIV care. She was diagnosed
with Pneumocystis pneumonia and HIV infection approximately
3 months prior. At the initial clinical visit, serologic testing
detected antibodies to Toxoplasma (IgG) and her most recent
CD4 count is 78 cells/mm 3 . Her only current medications is
dapsone; antiretroviral therapy will be started . She has a
history of a severe rash when taking trimethoprim sulfamethoxazole (Bactrim, Septra) approximately 1 year ago.
She is not sexually active and her last menstrual period was 2
weeks ago. Which one of the following would you recommend
for this patient regarding prophylaxis for Toxoplasma
encephalitis?
CASE 3, CONTINUED:
A. The patient's positive IgG antibody to Toxoplasma shows
evidence of immunity to Toxoplasma and thus she does not
need prophylaxis against Toxoplasma encephalitis.
B. The patient should receive prophylaxis for Toxoplasma
encephalitis and the dapsone she takes for Pneumocystis
prophylaxis will provide adequate prophylaxis against
Toxoplasma encephalitis.
C.
The patient should add atovaquone (Mepron) to the dapsone to
provide adequate prophylaxis for both Pneumocystis
pneumonia and Toxoplasma encephalitis.
D. The patient should receive prophylaxis for Toxoplasma
encephalitis. Dapsone alone does not provide sufficient
protection against reactivation of Toxoplasma; she should take
pyrimethamine and leucovorin in addition to dapsone
CASE 3: TOXOPLASMOSIS PROPHYLAXIS
A 4 8 - ye a r - o ld H I V - i n fe c te d w o m a n f r o m M ex i co p r e s e n t s to c l i n i c f o r p r i m a r y H I V c a r e .
S h e w a s d i a g n o s e d w i t h P n e u mo c ys t i s p n e u m o n i a a n d H I V i n f e c t io n a p p r ox i m a te l y 3
m o n t h s p r i o r. A t t h e i n i t i a l c l i n i c al v i s i t , s e r o l o g i c te s t i n g d ete c te d a n t i b o di e s to
Toxo p l a s m a ( I g G ) a n d h e r m o s t r e c e n t C D 4 c o u n t i s 7 8 c e l l s / m m 3 . H e r o n l y c u r r e n t
m e d i c a t io n s i s d a p s o n e ; a n t i r et rov i r al t h e r a py w i l l b e s t a r te d . S h e h a s a h i s to r y o f a
s ev e r e r a s h w h e n t a k i n g t r i m et h o p r i m - s ul f a m et h oxa z o le ( B a c t r i m , S e p t r a )
a p p r ox i m a tel y 1 ye a r a g o . S h e i s n o t s ex u a l ly a c t i ve a n d h e r l a s t m e n s t r ual p e r i o d
w a s 2 w e e k s a g o . W h i c h o n e o f t h e f o l l ow i n g w o u l d yo u r e c o m m e n d f o r t h i s p a t i e n t
r e g a r d i n g p r o p hy la x is f o r Toxo p l a s m a e n c e p h a l i t is ?
A.
T h e p a t i e n t ' s p o s i t i ve I g G a n t i b o d y to Toxo p l a s m a s h o w s ev i d e n c e o f i m m uni t y to
Toxo p l a s m a a n d t h u s s h e d o e s n o t n e e d p r o p hy l ax i s a g a i n s t Toxo p l a s m a
encephalitis.
B.
T h e p a t i e n t s h o u l d r e c e i ve p r o p hy l a x is f o r Toxo p l a s m a e n c e p h a l i t i s a n d t h e
d a p s o n e s h e t a ke s f o r P n e u mo c ys t i s p r o p hy l a x is w i l l p r o v i d e a d e q u a te
p r o p hy l ax i s a g a i n s t Toxo p l a s ma e n c e p h a l i t is .
C.
T h e p a t i e n t s h o u l d a d d a to v a q uo n e ( M e p r o n ) to t h e d a p s o n e to p r o v i d e a d e q u a te
p r o p hy l ax i s f o r b o t h P n e u m o c ys t i s p n e u m o ni a a n d Toxo p l a s m a e n c e p h a l i t i s.
D.
T h e p a t i e n t s h o u l d r e c e i ve p r o p hy l a x is f o r Toxo p l a s m a e n c e p h a l i t i s . D a p s o n e
a l o n e d o e s n o t p r o v i d e s u f fi c i e n t p r o te c t i o n a g a i n s t r e a c t i va t i on o f Toxo p l a s m a ;
s h e s h o u l d t a ke py r i m et h am i n e a n d l e u c ov o r in i n a d d i t i o n to d a p s o n e
CASE 3, ANSWER:
 The patient should receive prophylaxis for Toxoplasma
encephalitis. Dapsone alone does not provide sufficient
protection against reactivation of Toxoplasma; she should take
pyrimethamine and leucovorin in addition to dapsone.
 Trimethoprim-sulfamethoxazole is the simplest and most
effective prophylaxis for both Pneumocystis pneumonia and
Toxoplasma encephalitis, but this patient's severe skin rash
caused by trimethoprim-sulfamethoxazole necessitates her using
an alternative regimen. Dapsone alone is not effective as
prophylaxis against Toxoplasma encephalitis—it must be
combined with pyrimethamine and this regimen is the preferred
alternative to trimethoprim -sulfamethoxazole for prophylaxis
against Toxoplasma encephalitis. When pyrimethamine is used,
leucovorin should also be added to prevent leukopenia.
Pyrimethamine is contraindicated during pregnancy, but this was
not a concern in the patient presented.
PRIMARY OI PROPHYLAXIS: INITIATION
PRIMARY OI PROPHYLAXIS:
TERMINATION
CASE 4: IMMUNIZATIONS
A 35-year-old HIV-infected woman presents to clinic with
recently diagnosed HIV infection. Her risk factors for acquiring
HIV disease consist of injection -drug use and heterosexual sex
with a partner known to have HIV. Initial laboratory tests show a
CD4 count of 426 cells/mm 3 , HIV RNA of 32,000 copies/mm 3 ,
negative total hepatitis A virus antibody, negative hepatitis B
virus surface antigen, positive antibody to hepatitis B surface
antigen (anti-HBsAg), positive antibody to hepatitis B core
antigen (anti-HBc), and negative hepatitis C virus antibody. The
patient reports that she received all required childhood
vaccinations and received a tetanus booster 2 years ago, but
she does not recall ever having chicken pox or shingles. Which
one of the following would you recommended immunizations for
this patient?
CASE 4: IMMUNIZATIONS
A. Pneumococcal vaccine should be deferred until the patient’s
CD4 count declines to less than 200 cells/mm 3 .
B. The patient should receive the hepatitis A virus vaccine
series.
C. Influenza vaccine should not be given to this patient
because influenza vaccine is likely to cause a marked
increase in HIV RNA levels, a significant decline in CD4 cell
count, and an acceleration of HIV disease.
D. Varicella serology should be checked and, if negative, the
zoster vaccine (Zostavax) should be given.
CASE 4: IMMUNIZATIONS
A 35-year-old HIV -infected woman presents to clinic with recently diagnosed
HIV infection. Her risk factor s for acquiring HIV disease consist of injection drug use and heterosexual sex with a par tner known to have HIV. Initial
laborator y tests show a CD4 count of 426 cells/mm 3 , HIV RNA of 32,000
copies/mm 3 , negative total hepatitis A virus antibody, negative hepatitis B
virus sur face antigen, positive antibody to hepatitis B sur face antigen (anti HBsA g), positive antibody to hepatitis B core antigen (anti -HBc ), and negative
hepatitis C virus antibody. The patient repor ts that she received all required
childhood vaccinati ons and received a tetanus booster 2 year s ago, but she
does not recall ever having chicken pox or shingles. Which one of the
following would you recommended immunizations for this patient ?
A.
B.
C.
D.
Pneumococcal vaccine should be deferred until the patient’s CD4 count
declines to less than 200 cells/mm 3 .
The patient should receive the hepatitis A virus vaccine series.
Influenza vaccine should not be given to this patient because influenza
vaccine is likely to cause a marked increase in HIV RNA levels, a
significant decline in CD4 cell count, and an acceleration of HIV disease.
Varicella serology should be checked and, if negative, the zoster vaccine
(Zostava x ) should be given.
CASE 4: ANSWER
 The patient should receive the hepatitis A virus vaccine series.
 Hepatitis A vaccine is recommended for all HIV -infected
patients at risk of encountering hepatitis A including men who
have sex with men and injection drug users. This vaccine does
not contain live virus and does not pose any special risk to
HIV-infected persons.
ROUTINE IMMUNIZATIONS:
ROUTINE HEALTHCARE MAINTENANCE
BEHAVIORAL COUNSELING:
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Sexual health, secondary prevention, including PrEP
Substance abuse
Tobacco cessation
Domestic violence
Reproductive health, family planning
Diet and exercise
RESOURCES:
 http://www.hivguidelines.org
 http://www.hivguidelines.org/wp-content/uploads/2014/01/primary care-approach-to-the-hiv-infected-patient.pdf
 http://cid.oxfordjournals.org/content/early/2013/11/12/cid.
cit665.full.pdf
 http://www.hivwebstudy.org /
RESOURCES, CONTINUED:
RESOURCES, CONTINUED:
RESOURCES, CONTINUED: